WOTC Self-Attestation Form (ETA-9154)

Work Opportunity Tax Credit (WOTC) and Welfare-to-Work (WtW) Tax Credit

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1205-0371 can be found here:

Documents and Forms

Document Name Document Type
Form ETA-9154 WOTC Self-Attestation Form (ETA-9154) Form and Instruction
ETA-9154 YOUTH SELF-ATTESTATION FORM Work Opportunity Tax Credit WOTC Self Attestation Form 4-2-10.doc Form and Instruction
TEGL Change 3 3-30-10.doc TEGL 3-09 Change 3 IC Document

Information Collection (IC) Details

IC Title:	WOTC Self-Attestation Form (ETA-9154)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ETA-9154	YOUTH SELF-ATTESTATION FORM Work Opportunity Tax Credit Program	WOTC Self Attestation Form 4-2-10.doc		No		Paper Only

Line of Business: Workforce Management

Subfunction: Training and Employment

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 53	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Previously Approved
Annual Number of Responses for this IC	106,000	106,000
Annual IC Time Burden (Hours)	34,980	34,980
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
TEGL 3-09 Change 3	TEGL Change 3 3-30-10.doc	04/02/2010

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.